Standardized Queries Meet ICD-10
Another area where clinical documentation improvement (CDI) and ICD-10 should be coming together now is that of standardized queries. Where are your queries in the transition to ICD-10? Best practice suggests that you should look at them now and update them sooner; rather than later!
Most hospitals already have a series of standard queries in commonly occurring diagnoses. These may include such areas as:
- Heart Failure
- Surgical Debridement
- Sepsis vs. Bacteremia
- COPD / Asthma
- Renal disease
- Neurological conditions
These are some common examples, but certainly not all. The point is that standardized queries are already in place and with some diligence they can be used as a catalyst for better physician documentation under ICD-10. The process is fairly straight forward:
- Collect and review all existing queries
- For each query, identify what additional documentation will be needed to code correctly in ICD-10
- Assign staff to update the queries
- Slowly start using the new queries on current cases
- Use your physician champion to get physicians up to speed
By updating and using ICD-10 ready queries now, you'll bring physicians along slowly and minimize disruption at ICD-10 go-live. The updates should be written by a CDI specialist using the same criteria that went into the initial query. For example, do not lead the physician in a particular direction. Be general and let the physician give the appropriate documentation and let the diagnosis fall where it may.
Granted the issue of complication and co-morbidity (CC) and major complication and co-morbidity (MCC) is still an open item in ICD-10 and may require further changes to your queries. However, don't let this stop your progress. Keep your query updates going forward. After all CDI is an ongoing continuous process.